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CASE REPORT
Year : 2017  |  Volume : 18  |  Issue : 4  |  Page : 341-343

Habitual biting of a finger in a child


Department of Dermatology, Sundaram Medical Foundation and Dr. Rangarajan Memorial Hospital, Chennai, Tamil Nadu, India

Date of Web Publication29-Sep-2017

Correspondence Address:
M Riswana Jasmine
Old No 16/New No 33, Gandhi Road, Gill Nagar Extn., Choolaimedu, Chennai - 600 094, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2319-7250.193006

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  Abstract 


A 3-year-old male child was brought by his parents with a nonhealing ulcer on the right middle finger having no significant history except for an injury sustained to the right elbow in December 2013. On further probing, the mother revealed that the child used to indulge in habitual biting of his right middle finger while watching TV. Initially he was investigated extensively by a vascular surgeon and no abnormality was detected. He was later referred to the dermatology department and on examination, the patient was attentive with normal behaviour. The right upper limb was slightly larger than left. There was no deformity of the right elbow. The right third fingertip was enlarged and mutilated. There was no nerve thickening or hypopigmented patch. There was loss of sensation on the right hand and arm. Differential diagnosis of Lesch–Nyhan syndrome and congenital sensory neuropathy were considered. The patient was referred to a neurologist who investigated further with magnetic resonance imaging (MRI), and the final diagnosis of syringomyelia was made based on MRI findings.

Keywords: Lesch–Nyhan syndrome, nonhealing ulcer, syringomyelia


How to cite this article:
Sarveswari K N, Jasmine M R, Mahesh N. Habitual biting of a finger in a child. Indian J Paediatr Dermatol 2017;18:341-3

How to cite this URL:
Sarveswari K N, Jasmine M R, Mahesh N. Habitual biting of a finger in a child. Indian J Paediatr Dermatol [serial online] 2017 [cited 2019 Mar 24];18:341-3. Available from: http://www.ijpd.in/text.asp?2017/18/4/341/193006




  Introduction Top


Although nail biting is habitual in children, this case has been reported for its unique presentation as a nonhealing ulcer with a history of numbness over the tip of right middle finger due to a spinal pathology.

Syringomyelia is a rare disorder characterized by a longitudinal cyst in the cervical cord and/or medulla (syringobulbia) immediately anterior to the central canal, which spreads, usually asymmetrically, to each side. The most common cause is type I Chiari's syndrome where there is a congenital extension of the cerebellar tonsils below the foramen magnum. Symptoms usually appear in young adults, and the disease is generally slowly progressive over 20–30 years. This disease is characterized by dissociated sensory loss, in which pain and temperature sensation is lost early in the upper limb, while other sensory modalities carried in the posterior columns may remain relatively intact.

With the advent of magnetic resonance scanning, cases of syringomyelia are being detected earlier and a better understanding of the disease has been facilitated.


  Case Report Top


A 3-year-old male child was brought by his parents with a nonhealing ulcer on the right middle finger having no significant history except for an injury sustained to the right elbow in December 2013. On further probing, the mother revealed that the child used to indulge in habitual biting of his right middle finger while watching TV [Figure 1].
Figure 1: Nonhealing ulcer at the tip of middle finger

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Initially he was investigated by a vascular surgeon. Angiogram of the upper limbs showed dilated digital arteries and no aneurysm or vascular malformation. He was later referred to the dermatology department and on examination, the patient was attentive with normal behaviour. The right upper limb was slightly larger than left. There was no deformity of the right elbow. The right third fingertip was enlarged and mutilated. There was no nerve thickening or hypopigmented patch. There was loss of sensation on the right hand and arm. Sensation was normal on left. Differential diagnosis of Lesch–Nyhan syndrome and congenital sensory neuropathy were considered. The patient was referred to Neurologist who investigated further with magnetic resonance imaging (MRI), and the final diagnosis of syringomyelia was made based on MRI findings [Figure 2].
Figure 2: Magnetic resonance imaging of the spine showing the cerebellar tonsillar herniation suggesting Arnold– Chiari malformation More Details type 1

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  Discussion Top


Syringomyelia is a rare disorder characterized by a longitudinal cyst in the cervical cord and/or medulla (syringobulbia) immediately anterior to the central canal, which spreads, usually asymmetrically, to each side. The most common cause is type I Chiari's syndrome where there is a congenital extension of the cerebellar tonsils below the foramen magnum.[1] Incidence is around 8.4 cases per 100,000 persons.[2] Other causes include trauma and tumors. Symptoms usually appear in young adults, and the disease is generally slowly progressive over 20–30 years. This disease is characterized by dissociated sensory loss, in which pain and temperature sensation is lost early in the upper limb, while other sensory modalities carried in the posterior columns (e.g., touch, vibration, and position sense) may remain relatively intact.[3],[4] Earliest manifestation of the disease is a tendency to sustain painless burns and cuts on the hands and forearms. Occasionally, a combination of progressive pain loss, resultant skin ulceration, loss of soft tissue, resorption of the phalanges, and muscular atrophy (Morvan's syndrome) occurs.[5]

Body asymmetry or hemihypertrophy is known to occur in syringomyelia and can occur on the head and face. Hypertrophy of the hands and feet, together with hypertrophy of the bones and muscles in the same limb (especially in the upper limbs), has been described with syringomyelia. Many of the skin changes accompanying syringomyelia are the result of repeated burns or other injuries, particularly of the hands, where the skin over the fingers and knuckles may become thickened, swollen, cyanotic, and keratotic. The French term, “la main succulente,” refers to the swollen and edematous hands of syringomyelia sufferers. Syringomyelia is responsible for dyshidrosis with hyperhidrosis or hypohidrosis. Its distribution, which can be studied by thermography, correlates with the location of the syrinx and other neurological manifestation. Removal of the underlying pathology and establishing the normal cerebrospinal fluid flow is one of the mainstays of treatment.[6] In our case, the bony spur was surgically removed, and the child improved symptomatically. Mother was counseled to avoid injury.


  Conclusion Top


A good clinical examination and judicious use of investigation can lead us to the diagnosis of the underlying cause. This case report gives us an insight about unusual causes of a nonhealing ulcer. The timely intervention and counseling has helped the child from being investigated unnecessarily.

Acknowledgment

The authors acknowledge the contribution of Dr. N. Mahesh, M.D. (Pediatrics), D.M. (Neurology).

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Hauser SL, Ropper AH. Disease of the spinal cord, syringomyelia. In: Fauci A, Braunwald E, Kasper DL, Hauser SL, Longo DL, Jameson JL, et al., editors. Harrison's Principles of Internal Medicine. 17th ed., Ch. 372. New York: McGraw-Hill; 2008. p. 2594.  Back to cited text no. 1
    
2.
Rai SK, Rai PS. Volume change theory for syringomyelia: A new perspective. Asian J Neurosurg 2015;10:245-51.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Finlayson A. Syringomyelia and related conditions. In: Joynt RJ, editor. Clinical Neurology. Vol. 3, Ch. 45. Philadelphia: JB Lippincott Company; 1988. p. 1-17.  Back to cited text no. 3
    
4.
Mancall E. Syringomyelia. In: Rowland LP, editor. Merritt's Textbook of Neurology. Philadelphia: Lea and Feibeger; 1984. p. 552-6.  Back to cited text no. 4
    
5.
Charcot JM. Memoires, Notes, et Observations.1892. p.18.  Back to cited text no. 5
    
6.
Fox B, Muzumdar D, DeMonte F. Resolution of tonsillar herniation and cervical syringomyelia following resection of a large petrous meningioma: Case report and review of literature. Skull Base 2005;15:89-97.  Back to cited text no. 6
    


    Figures

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